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More is Better!
Our Field of Dream If you feed them (better!)They will leave (sooner!)
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Cahill N Crit Care Med 2010
In patients with high gastric residual volumes:use of motility agents 58.7% (site average range: 0-100%)
use of small bowel feeding 14.7% (range: 0-100%)
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“Minding the GAP” an Important Part of Patient Safety
The time to ACT is NOW!
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How to Change?
CPGs to bedsideGuidelines
Bedside
Dissemination and Implementation Strategies
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Special JPEN Issue Dedicated to KT
• Knowledge Translation (KT) – describes the process of moving evidence learned from
clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making.
– defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system.”
– Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept.
Available online nowIn press shortly
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Lost in (Knowledge) Translation!
Heyland DK, Cahill N, Dhaliwal R
Knowledge to Action Model by Graham
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Knowledge Generation
Knowledge To Action Model
Since 1980, >200 randomized trials of nutrition interventions
studying >2000 critically ill patients
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Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come!
(and where do we go from here?)
Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D
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Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come!
(and where do we go from here?)
Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D
Since 1980, 207 RCTs of Critical Care Nutrition Therapies
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Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come!
(and where do we go from here?)
Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D
Since 1980, 207 RCTs of Critical Care Nutrition Therapies
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Knowledge Synthesis
Knowledge – To- Action Model
Systematic reviews and meta-analyses
of 34 nutrition related topics
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Clinical Practice Guidelines
Knowledge – To- Action Model
Development of multiple Critical Care Nutrition
Clinical Practice Guidelines
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Guidelines, Guidelines, Guidelines. What Are We to do With all of These
North American Guidelines?
• Comparison of Canadian, American Dietetic Association, ASPEN/SCCM CPGs
• Different methods, studies included, ratings of evidence and values
• Similarities, minor and major differences in recommendations
• Can we harmonize this process?
Dhaliwal R, Madden S, Cahill N, Jeejeebhoy K, Kutsogiannis J, Muscedere J, McClave S, Heyland DK
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How to Narrow the Gap?First Define the Gap
International audits of nutrition practice
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Cahill N Crit Care Med 2010
In patients with high gastric residual volumes:use of motility agents 58.7% (site average range: 0-100%)
use of small bowel feeding 14.7% (range: 0-100%)
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Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within 24-48 hrs following resuscitation) in critically ill patients.
Value of Bench-marked Site Reports
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Early vs Delayed Nutrition Intake
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The Value of ‘Audit and Feedback Reports’ in Improving Nutritional
Therapy in the ICU: A Multicenter Observational Study
• 26 Canadian ICUs participating in 2007 and 2008 Surveys
Sinuff T, Cahill N, Dhaliwal R, Wang M, Day A, Heyland DK
(45.1% to 51.9%, p<0.001 and 44.8% to 51.5%, p<0.001 for calories and protein respectively
Adequacy of Calories from EN Only
20
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2007 2008
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Need to Understand Local Barriers
Assess Barriers
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Understanding Adherence to Guidelines in the ICU:
Development of a Comprehensive Framework
Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK
CPGCharacteristics
ADHERENCE
Implementation Process Institutional Factors Provider Intent
Hospital characteristics
-Structure- Processes-Resources
-Patient Case-mix Knowledge Attitudes
Familiarity
AwarenessMotivation Self-efficacy
Outcomeexpectancy
Agreement
ICU characteristics
-Structure- Processes-Resources
- Patient Case-mix-Culture
Provider Characteristics- Profession
-Critical care expertise-Educational background
-Personality
Patient Characteristics
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The Relationship Between Organizational Culture and Implementation of Clinical
Practice Guidelines: A Narrative Review
• “The way things are around here”• Major influence on CPG adherence• Defining, measuring, and changing
Dodek P, Cahill N, Heyland DK
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The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:
Results of a multicenter observational study• International, prospective, observational, cohort studies conducted in
2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries
• Included 5497 mechanically ventilated adult patients > 3 days in ICU
• Sites recorded the presence or absence of a feeding protocol
• Sites provided nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days.
0
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Protocol
No Protocol
P<0.05
78% of sites reported use of Feeding Protocol
Heyland DK, Cahill N, Dhaliwal R, Sun, Xiaoqun, Day A, McClave S
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Understanding Adherence to Guidelines in the ICU:
Development of a Comprehensive Framework
Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK
CPGCharacteristics
ADHERENCE
Implementation Process Institutional Factors Provider Intent
Hospital characteristics
-Structure- Processes-Resources
-Patient Case-mix Knowledge Attitudes
Familiarity
AwarenessMotivation Self-efficacy
Outcomeexpectancy
Agreement
ICU characteristics
-Structure- Processes-Resources
- Patient Case-mix-Culture
Provider Characteristics- Profession
-Critical care expertise-Educational background
-Personality
Patient Characteristics
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Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice
Guidelines: An International Survey of Critical Care Physicians and
Dietitians
Cahill N, Narasimhan S, Dhaliwal R, Heyland DK
• International web-based survey of 514 practitioners from 27 countries
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Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice
Guidelines: An International Survey of Critical Care Physicians and
Dietitians• Majority (91.4%) considered nutrition therapy to be very important
• Strong endorsement for the following established practices: enteral nutrition (EN) used in preference to parenteral nutrition (PN), use of polymeric solutions and feeding protocols, and avoiding hyperglycemia.
• Also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within 24-48 hours of admission, use of motility agents, head of the bed elevation, use of glutamine and antioxidants, and maximizing EN prior to starting PN.
• There was diversity of opinion on the recommendations pertaining to arginine-supplemented diets, small bowel feeding, use of pharmaconutrients, intensive insulin therapy, and withholding soybean oil lipids in PN solutions and hypocaloric PN.
Cahill N, Narasimhan S, Dhaliwal R, Heyland DK
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Understanding Adherence to Guidelines in the ICU:
Development of a Comprehensive Framework
Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK
CPGCharacteristics
ADHERENCE
Implementation Process Institutional Factors Provider Intent
Hospital characteristics
-Structure- Processes-Resources
-Patient Case-mix Knowledge Attitudes
Familiarity
AwarenessMotivation Self-efficacy
Outcomeexpectancy
Agreement
ICU characteristics
-Structure- Processes-Resources
- Patient Case-mix-Culture
Provider Characteristics- Profession
-Critical care expertise-Educational background
-Personality
Patient Characteristics
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Nutrition Therapy for the Critically Ill Surgical Patient: We Need to do Better!
• Combined 2007 and 2008 survey database
• 5497 mechanically ven’t patients >3days
• 37% surgical
Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day A, Heyland DK
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Need for a Tailored Approach
Select Intervention(s)
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Bridging the Guideline – Practice Gap In Critical Care Nutrition:
A Review of Guideline Implementation Studies
• 14 ICUs in Canada• 60 ICUs in Canada
• 27 ICUs in Australia
Cahill N, Heyland DK
GuidelinesBedside
3 Cluster RCTs
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Protocolize/automate careImprove organizational cultureDevelop Dietitian and other KOL as local opinion
leaders Audit and feedback with bench-marked site reports Assess barriers and have interactive workshops with
small group problem solving Implement strategies with rapid cycle change (PDSA)Educational reminders (manuals, posters, pocket
cards) One on one academic detailing
Practice Changing Interventions
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What works best at your site?
(barriers and enablers will vary site to site)
What is already working well at your site?
(strengths and weakness are different across sites)
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Vs.
Tailored Intervention:Change strategies specifically chosen to address the
barriers identified at a specific setting at a specific time
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Barriers are inversely related to nutrition performance and tailoring change strategies to overcome barriers to change will reduce the presence of these barriers
and lead to improvements in nutrition practice.
Hypothesis
PERFormance Enhancement of the Canadian nutrition guidelines through a Tailored Implementation Strategy:
The PERFECTIS Study
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And the Cycle continues...
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Creating a Culture of Clinical Excellence in Critical Care
Nutrition:
The ‘Best of the Best’ Award
Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A
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Recognition and Reward
Recognition a powerful
motivator of human
performance
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Recognition Produces Results!
• The results of a 10-year, 200,000 employee study:• Organizations excelling at rewarding excellence had avg.
ROE of 3x greater than the lowest rated organizations
• Institutions that excel at recognizing employee contributions:
– HIGHER in customer satisfaction
– HIGHER in employee satisfaction/morale (94.4% agree their superior is effective at recognition, only 2.4% with low morale agree)
– HIGHER in employee retention
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Determining the Best of the BestDeterminant WeightingOverall Adequacy of EN plus appropriate PN 10% patients receiving EN 5% of patients with EN initiated within 48 hours 3% of patients with high gastric residual volumes (HGRV) receiving motility agents
1
% of patients with HGRV receiving small bowel tubes 1% of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best)
3
Rank all eligible ICUs by determinantsMultiply ranking by weightingICU with highest score is crowned ‘Best of the Best’
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Best of the Best Award
• Eligible sites: Data on 20 critically ill patients Complete baseline nutrition assessment Presence of feeding protocol No missing data or outstanding queries Permit source verification by CCN
• Awarded to ICU that demonstrate: Highest ranking nutritional performance
BEST OF THE BEST
KGH
2008
Last year, 156 ICUs participated in an international audit of nutrition practices in critically ill patients. This year we want to take part.
Please help us to improve our performance as it relates to nutrition in our ICU. Better nutrition therapy translates into reduced
morbidity and improved survival.
For more information, contact____________________
ADD HOSPLOGO
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2008 Best of the Best
Top 3 ICUs1. Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
2. Kingston General Hospital, Kingston, Canada
3. Regional Hospital A. Cardarelli, Italy
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Lyn Gillanders, Senior Clinical Dietitian and her ICU colleagues at the Department of Critical Care Medicine,
Auckland City Hospital being presented with the Best of the Best Award by the Hospital Medical Director.
2008Best of the Best
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Determinants to Top PerformanceWhat site and hospital characteristics are associated with top BOB ranking?
Hospital/ICU characteristics** Ranking p values
Region
Australia and New Zealand vs. Canada -3.0 0.61
China vs. Canada +30.4 0.008
Europe and South Africa vs. Canada -7.9 0.22
India vs. Canada +32.7 0.08
Latin America vs. Canada 0.17 0.98
USA vs. Canada +30.4 <0.0001
Hospital size (per 100 beds) -0.24 0.78
ICU structure
Closed vs. open or other -0.89 0.89
Presence of Dietitian(s)
Yes vs. No -23.5 0.005
(Best Rank=1rst thus a negative number is associated with a better ranking)
Heyland JPEN 2010
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2009 Best of the BestOf >200 ICUS competing Internationally
1. Instituto Neurologico de Antioquia, Medellin, Colombia
1. Royal Prince Alfred Hospital, Sydney, Australia
1. The Alfred, Melbourne, Australia
TOP Performers
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2009 Best of the BestOf >200 ICUS competing Internationally
4) Trillium Health Centre, Mississauga, Canada5) Regional Hospital A. Cardarell, Campobasso, Italy6) Royal Columbian Hospital, New Westminster, Canada7) Community Hospital of Monterey Peninsula,
Monterey, USA8) Auckland City Hospital, Auckland, New Zealand9) Hamilton General Hospital, Hamilton, Canada10)University District Hospital Neuro-ICU, San Juan, USA
Outstanding Performers
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How to Change?
CPGs to bedside
Bedside
Dissemination and Implementation Strategies